Well, the obvious question is if Assertive Community Treatment is so great, why don't we have more of it? For the State, the answer is cost. And for the mental health activist community, the concern is that "Assertive" can become "Coercive." With respect to cost, see NAMI's ACT Cost Summary. With respect to "Coercion," I think such concerns can be addressed as were done below in New York AND regardless of whether a civil liberties provision is incorporated in a certification manual, rule, or statute -- it still has to be actualized and enforced.
ACT 3.12 Recipient Rights
Recipients are informed of their rights and their rights are respected.
The program incorporates recipient input into program practices and provides full, immediate access to their charts. Recipients shall be able to object to their treatment, or complain or discuss issues related to program policies and procedures, program staff or services without fear of retribution (Grievance procedure).
Recipients have a right to culturally sensitive and competent treatment and services.
One of the things that gets bandied about with ACT is Intensive Case Management (ICM). In some of the literature, ICM is referred to as ACT-lite. My experience with ICM is that in certain circumstances it just isn't enough. I find that folks in the system may say, "That's all he needs, someone to check in with on a daily basis and help him with a mountain of complex social work needs that resist the best good faith efforts at resolution of multiple people in multiple executive departments." (I'm paraphrasing of course). Yeah that's really all he needs AND he can't get it, AND we've been working on this for over 6 months AND my guy is still homeless AND still NOT getting the level of assistance he needs. So my take is the proof is in the pudding -- if ICM can keep someone from being homeless, hospitalized, or incarcerated that's great -- if not more services are needed. See below an interesting review of literature which found the "weakest outcomes" with ICM alone.
A review of 16 controlled outcome evaluations of housing and support interventions for people with mental illness who have been homeless revealed significant reductions in homelessness and hospitalization and improvements in other outcomes (e.g., well-being) resulting from programs that provided permanent housing and support, assertive community treatment (ACT), and intensive case management (ICM). The best outcomes for housing stability were found for programs that combined housing and support (effect size = .67), followed by ACT alone (effect size = .47), while the weakest outcomes were found for ICM programs alone (effect size = .28). The results of this review were discussed in terms of their implications for policy, practice, and future research.
American Journal of Orthopsychiatry (2007)
We need to cost it out and seek additional funding this legislative session for Medicaid Assertive Community Treatment for people where it is "reasonably medically necessary." Failure to do so, amounts to the continued unwitting discrimination of people with mental illness. It's time to ACT!
PRINCIPLES OF ACT Assertive Community Treatment services adhere to certain essential standards and the following basic principles:
PRIMARY PROVIDER OF SERVICES: The multidisciplinary make-up of each team (psychiatrist, nurses, social workers, rehabilitation, etc.) and the small client to staff ratio, helps the team provide most services with minimal referrals to other mental health programs or providers. The ACT team members share offices and their roles are interchangeable when providing services to ensure that services are not disrupted due to staff absence or turnover.
SERVICES ARE PROVIDED OUT OF OFFICE: Services are provided within community settings, such as a person's own home and neighborhood, local restaurants, parks and nearby stores.
HIGHLY INDIVIDUALIZED SERVICES: Treatment plans, developed with the client, are based on individual strengths and needs, hopes and desires. The plans are modified as needed through an ongoing assessment and goal setting process.
ASSERTIVE APPROACH: ACT team members are pro-active with clients, assisting them to participate in and continue treatment, live independently, and recover from disability.
LONG-TERM SERVICES: ACT services are intended to be long-term due to the severe impairments often associated with serious and persistent mental illness. The process of recovery often takes many years.
EMPHASIS ON VOCATIONAL EXPECTATIONS: The team encourages all clients to participate in community employment and provides many vocational rehabilitation services directly.
SUBSTANCE ABUSE SERVICES:The team coordinates and provides substance abuse services.
PSYCHOEDUCATIONAL SERVICES: Staff work with clients and their family members to become collaborative partners in the treatment process. Clients are taught about mental illness and the skills needed to better manage their illnesses and their lives.
FAMILY SUPPORT AND EDUCATION: With the active involvement of the client, ACT staff work to include the client's natural support systems (family, significant others) in treatment, educating them and including them as part of the ACT services. It is often necessary to help improve family relationships in order to reduce conflicts and increase client autonomy.
COMMUNITY INTEGRATION: ACT staff help clients become less socially isolated and more integrated into the community by encouraging participation in community activities and membership in organizations of their choice.
ATTENTION TO HEALTH CARE NEEDS: The ACT team provides health education, access, and coordination of health care services.